Ulcerative colitis medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Tarek Nafee, M.D. [2]


The first step in the management of an acute ulcerative colitis attack involves determining the anatomical extent of the disease endoscopically, and the severity of the disease, clinically. This classification is important to determine the necessity for topical (in distal disease) or systemic (in extensive disease) pharmacotherapy. Additionally, the severity of the disease may help determine the prognosis and the requirement for more aggressive intervention. Once the disease goes into remission, the goal of maintenance therapy is to prevent any subsequent acute exacerbations.

Medical Therapy

The goal of medical therapy is to induce remission initially with medications, followed by the administration of maintenance medications to prevent a relapse of the disease. The concept of induction of remission and maintenance of remission is very important. The medications used to induce and maintain a remission somewhat overlap, but the treatments are different. Physicians first direct treatment to inducing a remission which involves relief of symptoms and mucosal healing of the lining of the colon and then longer term treatment to maintain the remission.

Standard treatment for ulcerative colitis depends on extent of involvement (proximal vs. distal) and disease severity (e.g. mild, moderate, severe and fulminant) as follows: [1]

  • 1. Mild to Moderate Distal Colitis
    • Acute Management
      • Preferred regimen (1): Topical Mesalamine
      • Preferred regimen (2): Topical corticosteroids
      • Preferred regimen (3):Oral aminosalicylates
      • Alternative regimen (1): Mesalamine enemas or suppositories (in patients refractory to topical corticosteroids or oral aminosalicylates.
      • Alternate regimen (2): Oral prednisone up to 40-60 mg/day AND infliximab 5mg/kg at weeks 0, 2, 6 of treatment
        • Note: Effective dose of Sulfasalazine is 4-6g/day in 4 doses; mesalamine is 2-4.6g/day in 3 doses; balasalazine 6.75g/day in 3 doses; mesalamine multimatrix formulation is 2.4 to 4.8 g/day. These drugs are effective within 2.4 weeks.
  • 2. Mild to Moderate Extensive Colitis
    • Acute Management
      • Preferred regimen (1): oral sulfasalazine titrated up to 4-6g/day OR oral aminosalicylate in doses of up to 4.8g/day of active 5-ASA moiety
      • Alternate regimen (1): Oral steroids (in patients refractory to aminosalicylates in combination with topical therapy)
      • Alternate regimen (2): 6-mercaptopurine AND azathioprine (in patients refractory to oral steroids)
      • Alternative regimen (3): infliximab 5mg/kg I.V. at weeks 0,2, and 6 (steroid refractory or steroid dependent despite adequate 6-MP dosing or intolerant to other regimens)
        • Note (1): Infliximab is contraindicated in patients with untreated latent TB, pre-existing demyelinating disorder, optic neuritis, moderate to severe CHF, current or recent malignancy
        • Note (2): Transdermal nicotine is effective in achieving remission.
  • 3.Severe Colitis
    • Acute Management
      • Preferred Regimen (1): Maximal oral treatment with prednisone AND oral aminosalicylate drugs AND topical mesalamine
      • Alternate regimen (2): Infliximab 5mg/kg (if refractory and urgent hospitalization is not necessary)
      • Alternate regimen (3): Intravenous corticosteroids (if patient presents with toxicity)
    • Preferred Regimen (1): Metronidazole 400mg q8h OR 20mg/kg daily
    • Preferred Regimen (2): Ciprofloxacin 500mg bid
      • Note: Other etiologies mimicking pouchitis include irritable pouch syndrome, cuffitis, CD of the pouch, and postoperative complications such as anastomotic leak or stricture.



Sulfasalazine has been a major agent in the therapy of mild to moderate UC for over 50 years. In 1977 Mastan S.Kalsi et al determined that 5-aminosalicyclic acid (5-ASA and mesalazine) was the therapeutically active compound in sulfasalazine. Since then many 5-ASA compounds have been developed with the aim of maintaining efficacy but reducing the common side effects associated with the sulfapyridine moiety in sulfasalazine.[2]


Immunosuppressive drugs

Biological treatment

Contraindicated medications

Ulcerative colitis is considered an absolute contraindication to the use of the following medications:


  1. Kornbluth A, Sachar DB, Practice Parameters Committee of the American College of Gastroenterology (2010). "Ulcerative colitis practice guidelines in adults: American College Of Gastroenterology, Practice Parameters Committee". Am J Gastroenterol. 105 (3): 501–23, quiz 524. doi:10.1038/ajg.2009.727. PMID 20068560.
  2. S. Kane (2006). "Asacol - A Review Focusing on Ulcerative Colitis".

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